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Try dive registration TossaDIvers
"
*
" indicates required fields
Name
*
Surnames
*
Date of birth
*
DD slash MM slash YYYY
Email
*
Teléfono
*
Are you of legal age?
*
Yes
No
Legal guardian data
*
First
Last
Legal guardian signature
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1 - I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.(If you answer YES, answer questions A)
*
Yes
No
2 - I am over 45 years of age.(If you answer YES, answer questions B)
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Yes
No
3 - I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.
*
Yes
No
4 - I have had problems with my eyes, ears, or nasal passages/sinuses. (If you answer YES, answer questions C)
*
Yes
No
5 - I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.
*
Yes
No
6 - I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease(If you answer YES, answer questions D)
*
Yes
No
7 - I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.(If you answer YES, answer questions E)
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Yes
No
8 - I have had back problems, hernia, ulcers, or diabetes (If you answer YES, answer questions F)
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Yes
No
9 - I have had stomach or intestine problems, including recent diarrhea (If you answer YES, answer questions G)
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Yes
No
10 - I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).
*
Yes
No
Section A
A1 - Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease
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Yes
No
A2 — Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise
*
Yes
No
A3 — A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
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Yes
No
A4 — Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
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Yes
No
A5— Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance
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Yes
No
Section B
B1 - I am over 45 years old and currently smoke or inhale nicotine through other means.
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Yes
No
B2 - I am over 45 years old and have high cholesterol.
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Yes
No
B3 - I am over 45 years old and have high blood pressure.
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Yes
No
B4 - I am over 45 years old and have had a family member (1st or 2nd degree of consanguinity) who died of sudden death, heart disease or stroke before the age of 50, or I have a family history of heart disease before the age of 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
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Yes
No
Section C
C1 - I have/had: Sinus surgery in the last 6 months.
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Yes
No
C2 - I have/had: Ear disease or ear surgery, hearing loss or balance disorders.
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Yes
No
C3 - I have/had: Recurrent sinusitis in the last 12 months.
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Yes
No
C4 - I have/had: Eye surgery in the last 3 months.
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Yes
No
Section D
D1 - I have/had: Head injury with loss of consciousness in the last 5 years.
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Yes
No
D2 - I have/had: Persistent neurological injuries or illnesses.
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Yes
No
D3 - I have/had: Recurrent migraine headaches in the last 12 months, or take medication to prevent them.
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Yes
No
D4 - I have/had: Fainting spells or loss of consciousness (partial or total) in the last 5 years.
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Yes
No
D5 - I have/had: Epilepsy, seizures or convulsions, or take medication to prevent them.
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Yes
No
Section E
E1 - I have/had: Behavioral health, mental or psychological problems that require medical or psychiatric treatment.
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Yes
No
E2 - I have/had: Major depression, suicidal tendencies, panic attacks, uncontrolled bipolar disorder that requires medication/psychiatric treatment.
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Yes
No
E3 - I have/had: Been diagnosed with a mental health condition or a learning or developmental disorder that requires ongoing attention.
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Yes
No
E4 - I have/had: An addiction to drugs or alcohol that requires treatment in the last 5 years.
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Yes
No
Section F
F1 - I have/had: Recurrent back problems in the last 6 months that limit my daily activity.
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Yes
No
F2 - I have/had: Back or spinal surgery in the last 12 months.
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Yes
No
F3 - I have/had: Diabetes, either controlled by insulin or diet, or gestational diabetes in the last 12 months.
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Yes
No
F4 - I have/had: An uncorrected hernia that limits my physical abilities.
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Yes
No
F5 - I have/had: Active or untreated ulcers, problem wounds, or ulcer surgery in the last 6 months.
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Yes
No
Section G
G1 - I have: Ostomy surgery and do not have medical authorization to swim or engage in physical activity.
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Yes
No
G2 - I have: Dehydration that requires medical intervention in the last 7 days.
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Yes
No
G3 - I have: Active or untreated stomach or intestinal ulcers, or ulcer surgery in the last 6 months.
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Yes
No
G4 - I have: Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).
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Yes
No
G5 - I have: Active or uncontrolled ulcerative colitis or Crohn's disease.
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Yes
No
G6 - I have: Bariatric surgery in the last 12 months.
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Yes
No
Acceptance of the declaration.
If you answered YES to questions 3, 5, or 10 above, or to any of the questions on the questionnaire, download, read, and accept the statement with the date and your signature, and take the Medical Evaluation Form to your physician for a medical evaluation. Participation in a scuba training program requires evaluation and approval from your physician.
*
I acknowledge that I have answered all questions truthfully. If you answered YES to any of the above questions,
download the Medical Questionnaire
and take it to your physician to authorize you for underwater activities.
Participant Statement: I have answered all questions honestly and understand that I accept responsibility for any consequences resulting from any question I may have answered inaccurately or for not disclosing any existing or past health condition.
*
I have read and accept the participant statement.
Signature
*
